Lowering of intraocular pressure after phacoemulsification in primary open-angle and angle-closure glaucoma: Correlation with lens thickness

Purpose: To assess anterior chamber configuration changes during phacoemulsification in primary angle?closure suspect (PACS/PAC) and primary open?angle glaucoma (POAG). Methods: Prospective observational comparative study of anterior segment optical coherence tomography (AS?OCT) findings before and after phacoemulsification on three groups of patients (PACS/PAC, POAG, and controls). Data were collected over a period of 9 months. Main outcome measures included mean change in anterior chamber depth (ACD), angle opening distance (AOD), and trabecular iris space area (TISA). Results: 153 patients (51 PACS/PAC, 51 POAG, and 51 controls) were included in the study. Change in all parameters (ACD, AOD at 500 um, and AOD at 750 um) between the groups demonstrated a greater change in PACS/PAC as compared to POAG and controls. AOD at 750 ?m in the temporal quadrant, which has been considered to be having the highest correlation or best representation of the angle, increased in all groups after phacoemulsification (463.59 ± 10.99 vs. 656.27 ± 9.73 mm in PACS; 521.29 ± 16.36 vs. 674.37 ± 8.72 mm in POAG; 549.27 ± 12.40 vs. 702.82 ± 13.04 mm in controls, (P < 0.001). After phacoemulsification, intraocular pressure (IOP) decreased by 2.75 ± 1.17 mm Hg in PACS/PAC (P < 0.001), 2.14 ± 1.33 mm Hg in POAG and 1.90 ± 1.25 mm Hg in controls and it was statistically significant in the PACS group compared to control (P < 0.001). Conclusion: Phacoemulsification with intraocular lens implantation is associated with increase in the ACD and angle parameters and a corresponding decrease in IOP. Findings were more pronounced in PACS/PAC suggesting early phacoemulsification may be a treatment option in this group

Open angle glaucoma in a case of Type IV Ehler Danlos syndrome: A rarely reported association.

A 26-year-old male presented to us with defective vision in the left eye. He had best corrected visual acuity (BCVA) of hand movement (HM) in right eye and 6/9 in left eye. He had ptosis with ectropion in both eyes and relative afferent pupillary defect (RAPD) in right eye. Intraocular pressure (IOP) was 46 and 44 mmHg in right and left eye, respectively. Fundus showed glaucomatous optic atrophy (GOA) in right eye and cup disc ratio (CDR) of 0.75 with bipolar rim thinning in left eye. Systemic examination showed hyperextensible skin and joints, acrogeria, hypodontia, high arched palate, and varicose veins. He gave history of easy bruising and tendency to fall and history of intestinal rupture 5 years ago for which he had undergone surgery. He was diagnosed as a case of Type IV Ehler-Danlos syndrome (EDS) with open angle glaucoma. He underwent trabeculectomy in both eyes. This is a rare case that shows glaucoma in a patient of EDS Type IV. Very few such cases have been reported in literature.

Anterior segment optical coherence tomography documentation of a case of topiramate induced acute angle closure.

We present a case report of a 31-year-old female patient who presented to us with a 1 day history of acute bilateral eye pain, blurred vision and headache. She was found to have a myopic shift, raised intraocular pressure (IOP) and shallow anterior chambers in both eyes. She had been commenced on oral topiramate 1 week previously. A number of investigations, including anterior segment optical coherence tomography (AS-OCT) were done and a diagnosis of topiramate induced bilateral acute angle closure (TiAAC) was made. Topiramate was discontinued and she was managed with topical and oral antiglaucoma medications, topical steroids and cyclopegics. Her symptoms subsided dramatically at the next follow-up. The AS-OCT documentation revealed lucidly the improvement in her anterior chamber depth and anterior chamber angle parameters. Her IOP decreased, her myopic shift showed reversal and her AS-OCT fi ndings revealed gross improvement in all the parameters angle opening distance, trabecular iris space area and scleral spur angle. This case report clearly shows with AS OCT documentation the changes which occur in the anterior segment in a case of TiAAC.

Visual prognosis, intraocular pressure control and complications in phacomorphic glaucoma following manual small incision cataract surgery.

Aims: To evaluate intraocular pressure (IOP) control, visual prognosis and complications following manual small incision cataract surgery among eyes with phacomorphic glaucoma. Materials and Methods: This prospective, non-randomized interventional consecutive case series included all patients with phacomorphic glaucoma who presented to a tertiary eye care referral center in South India between March 2006 and April 2007. All patients underwent slit-lamp bio-microscopy, applanation tonometry and gonioscopy of the other eye to rule out angle closure. Small incision cataract surgery with intraocular lens implantation was performed in all affected eyes. Complete ophthalmic examination was done at each follow-up visit. Results: A total of 74 eyes with phacomorphic glaucoma were included in this study. The preoperative mean IOP was 38.4±14.3 mmHg and mean IOP at last follow-up was 12.7±2.4 mmHg. There was a statistically significant difference between IOP at presentation and IOP at last follow-up (P< 0.001). None of the eyes required long-term antiglaucoma medication. No significant intraoperative complications were noted. The final postoperative best corrected visual acuity was 20/40 or better in 51 patients. Eighteen eyes had corneal edema and 36 eyes had anterior chamber inflammation. Both conditions resolved with standard medical therapy. Conclusion: Manual small incision cataract surgery is safe and effective in controlling IOP and achieving good functional visual acuity with minimal complications in the management of phacomorphic glaucoma in developing countries.

Optic disc morphometry with optical coherence tomography: comparison with planimetry of fundus photographs and influence of parapapillary atrophy and pigmentary conus.

PURPOSE: Optical coherence tomography (OCT) is an established method for visualising macular pathology and for measuring the thickness of parapapillary retinal nerve fibre layer. The purpose of the present study was to compare OCT measurements of the optic disc with those obtained by planimetry of fundus photographs and to investigate whether OCT measurements are influenced by the amount of parapapillary atrophy or pigmentary conus at the disc margin. MATERIALS AND METHODS: Eighty-two eyes of 41 randomly selected Asian-Indian subjects were included.The mean age was 44.2+/-14.3 years (mean+/-SD). All eyes underwent optic disc assessment by OCT (fast optical disc protocol) and digital 20 degree disc photos.. Planimetry of the discs were performed by outlining the disc and the cup. The amount of parapapillary atrophy (zone beta) was quantified as the number of clock-hours around the disc with adjacent parapapillary atrophy. The same procedure was performed to quantify the amount of pigmentary conus around the disc. RESULTS: Mean+/-SD disc size and mean+/-SD cup size in OCT measurements (2.37+/-0.51, 1.29+/-0.55) were significantly smaller than in photographic planimetry (2.83+/-0.62, 1.56+/-0.5: P<0.001, P<0.001). Optic discs with parapapillary atrophy (P=0.2) in their relative difference of disc sizes between OCT and planimetry. Similarly, optic discs with pigmentary conus (n=12) and discs without pigmentary conus (n=70) did not differ significantly (P=0.65). The relative difference in disc size between the two measurement modalities did not correlate with the amount of parapapillary atrophy (r=-0.17, P=0.29) or with the amount of pigmentary conus (r=-0.04, P=0.9). CONCLUSION: OCT analysis of the optic disc produces significantly smaller parameters, compared to the established method of optic disc planimetry. Neither presence, nor extent of parapapillary atrophy zone beta and pigmentary conus seems to produce a systematic error in measurements of disc size with the OCT.